VA Form 10-10EZR Health Benefits Renewal Form

INSTRUCTIONS FOR COMPLETING
HEALTH BENEFITS RENEWAL FORM

Please Read Before Your Start ... What is VA Form 10-10EZR used for?
To update your personal, insurance, or financial information after you are enrolled. The information provided on this form will be
used by VA to determine your eligibility for medical benefits and on average will take 24 minutes to complete. This includes the time
it will take to read instructions, gather necessary facts and fill out the form.

Where can I get help filling out the form or if I have questions?
You may use ANY of the following to request assistance:
Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
Access our website at http://www.va.gov and select "Contact the VA."
Contact the Enrollment Coordinator at your local VA health care facility.
Contact a National or State Veterans Service Organization.

Definitions of terms used on this form
SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in
the active military, naval or air service.
COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
NONSERVICE-CONNECTED (NSC): A veteran who does not have a VA determined service-related condition.

Getting Started: All Veterans must complete Sections I-III
Directions for Sections I - III

Section I - General Information: Answer all questions
Section II - Insurance Information: Include information for all health insurance companies that cover you, this
includes coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or
Medicaid card with you to each health care appointment.
Section III - Employment Information: If you are employed or retired, answer all questions.
Directions for Sections IV - VIII:
Section IV - Financial Disclosure: Disclosure allows VA to accurately determine whether certain Veterans will be charged

copays for care and medications, their eligibility for other services and enrollment priority. Veterans are not required to
disclose their financial information. If you elect not to disclose: VA will use its electronic matching authorities to query
such information as may be required from the Internal Revenue Service and/or Social Security Administration.
Veterans will only be contacted if there is a discrepancy in the information reported or if other required information is
needed.

ONLY NSC and 0% NONCOMPENSABLE SERVICE-CONNECTED VETERANS COMPLETE THIS
SECTION TO DETERMINE ELIGIBILITY AND COPAY RESPONSIBILITIES. FINACIAL
DISCLOSURE DO NOT APPLY TO: a former Prisoner of War or; in receipt of a Purple Heart or; a recently
discharged Combat Veteran or; discharged for a disability incurred or aggravated in the line of duty or; receiving
VA service-connected disability compensation or; receiving VA pension or; in receipt of Medicaid benefits or;
those who served in Vietnam between January 9, 1962 and May 7, 1975 or; those who served in SW Asia during
the Gulf War between August 2, 1990 and November 11, 1998 or; those who served at Camp Lejeune between
January 1, 1957 and December 31, 1987.
Section V - Dependent Information: Your spouse and dependent social security numbers(s) are required so we can
verify their financial and insurance information through a computer-matching program.
Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children:
Answer applicable questions
Section VII - Previous Calendar Year Deductible Expenses: Answer applicable questions
Section VIII - Previous Calendar Year Net Worth: Answer applicable questions
NOTE: All other Veterans may wish to provide this financial assessment to determine, as applicable, their eligibility
for cost-free medication, beneficiary travel eligibility and/or waiver of the beneficiary travel deductible requirement.
VA FORM
FEB 2011

10-10EZR

Complete only the sections that apply to you and sign and date the form.

Additional Information for Completing your application ...

Answer all questions in the appropriate sections. If you need more space to answer a question, attach a sheet of paper to the form
containing your name and Social Security Number. For each question that you need more room, write "Continuation of Item" and
write the section and question number.

Section II - Insurance Information.

Include information for all health insurance policies that cover you, this includes coverage that is provided through a spouse or
significant other. If you have more than one health insurer, provide this information on a separate sheet of paper and attach to the
application. If you have access to a copier, attach a copy of your insurance cards, Medicare card and/or Medicaid card (Medicaid is
a federal/state health insurance program for certain low-income people). Bring these cards with you to each health care
appointment.

Section IV - Financial Disclosure.

The financial assessment is used to determine whether certain Veterans qualify for cost-free health care services for their NSC
conditions and to assign their priority for enrollment, if your eligibility for health care benefits requires or may be based on a
financial assessment. You are not required to disclose your financial information.
If you elect not to disclose: VA will use its electronic matching authorities to query such information as may be required
from the Internal Revenue Service and/or Social Security Administration. Veterans will only be contacted if there is a
discrepancy in the information reported or if other required information is needed.

Section V - Dependent Information.
You may count your spouse as your dependent even if you did not live together, as long as you contributed support last calendar year.
You may count your biological children, adopted children, and stepchildren as dependents. But these children must be unmarried
and under the age of 18, or be at least 18 but under 23 and attending high school, college or vocational school on a full or part-time
basis, or have become permanently unable to support themselves before reaching the age of 18.
Count child support contributions even if not paid in regular set amounts. Contributions can include tuition payments or payments
of medical bills.

Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.

Report:
Gross annual income from employment, except for income from your farm, ranch, property or business, including information
about your wages, bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have
been used to pay your household expenses.
Net income from your farm, ranch, property or business.
Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability
income, compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends,
including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.
Do Not Report:
Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI)and need-based
payments from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on
Individual Retirement Accounts (IRAs); scholarships and grants for school attendance; disaster relief payment; reimbursement for
casualty loss; loans; Radiation Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims
Settlement Acts Income, payments to foster parent; amounts in joint accounts in banks and similar institutions acquired by reason of
death of the other joint owner; Japanese ancestry restitution under Public Law 100-383; cash surrender value of life insurance; lumpsum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional assistance program.

Section VII - Previous Calendar Year Deductible Expenses.

Report nonreimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs,
eyeglasses, Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom
you have a legal or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other
sources. Report expenses of last illness and burial expenses, e.g., prepaid burial, paid by the veteran for spouse or dependent(s).

Section VIII - Previous Calendar Year Net Worth.

Your net worth is the market value of all the interest and rights you have in any kind of property. However net worth does not
include your single-family residence and a reasonable lot area surrounding it. It also does not include the personal things you use
every day like your vehicle, clothing and furniture.

Submitting your application ...

1. Read Section IX (Paperwork Reduction and Privacy Act Information), Section X (Consent to Copayments), and Section XI
(Assignment of Benefits).
2. Make sure you sign and date VA Form 10-10EZR in Section XI. You or an individual to whom you have delegated your Power
of Attorney must sign and date the form. If you sign with an "X", then you must have 2 people you know witness you as you
sign. They must then sign the form and print their names. If the form is not signed and dated appropriately, VA will return it for
you to complete. This will result in a delay in processing your application.
3. Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.

Where do I send my application?

Mail the original application and supporting materials to your local VA health care facility. You can find the address by calling
VA at 1-877-222-VETS (8387), or on the Internet at http://www.va.gov.
VA FORM
FEB 2011

10-10EZR

OMB Approved No. 2900-0091
Estimated Burden Avg. 24 min.

HEALTH BENEFITS RENEWAL FORM
SECTION I - GENERAL INFORMATION

Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact
or making a materially false statement. (See 18 U.S.C. 1001)
1. VETERAN'S NAME (Last,

First, Middle Name)

3. GENDER

2. OTHER NAMES USED

4. SOCIAL SECURITY NUMBER

MALE

5. DATE OF BIRTH

(mm/dd/yyyy)

FEMALE

6. PERMANENT ADDRESS

(Street)

6B. STATE

6A. CITY

6D. COUNTY

6E. HOME TELEPHONE NUMBER (Include

6F. E-MAIL ADDRESS

6G. CELLULAR TELEPHONE NUMBER (Include

one)
NEVER MARRIED

6C. ZIP

area code)
area code)

7. CURRENT MARITAL STATUS (Check

MARRIED

SEPARATED

WIDOWED

8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN

9. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT (if different than 8)

DIVORCED

UNKNOWN

8A. NEXT OF KIN'S HOME TELEPHONE NUMBER (Include

area code)

8B. NEXT OF KIN'S WORK TELEPHONE NUMBER (Include

area code)

9A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER

(Include area code)

9B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER (Include

area code)

SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)
1. ARE YOU COVERED BY HEALTH INSURANCE, INCLUDING COVERAGE
THROUGH A SPOUSE OR ANOTHER PERSON?

YES

2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

NO

3. NAME OF POLICY HOLDER

4. POLICY NUMBER

5. GROUP CODE

6. ARE YOU ELIGIBLE FOR MEDICAID?

YES
7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?

YES

NO

YES

NO

8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?

9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD

6A. EFFECTIVE DATE (mm/dd/yyyy)

NO

7A. EFFECTIVE DATE (mm/dd/yyyy)
8A. EFFECTIVE DATE (mm/dd/yyyy)
10. MEDICARE CLAIM NUMBER

SECTION III - EMPLOYMENT INFORMATION
1. VETERAN'S EMPLOYMENT
STATUS (check one)

If employed or retired,
complete item 1A
2. SPOUSE'S EMPLOYMENT
STATUS (check one)

If employed or retired,
complete item 2A

1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
FULL TIME

NOT EMPLOYED

PART TIME

RETIRED

FULL TIME

NOT EMPLOYED

PART TIME

RETIRED

Date of retirement
(mm/dd/yyyy)
2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

Date of retirement
(mm/dd/yyyy)

SECTION IV - FINANCIAL DISCLOSURE

Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their eligibility
for other services and enrollment priority. Veterans are not required to disclose their financial information. If you elect not to disclose:
VA will use its electronic matching authorities to query such information as may be required from the Internal Revenue Service
and/or Social Security Administration. Veterans will only be contacted if there is a discrepancy in the information reported or if
other required information is needed.
Recently (within five years post discharge) discharged veterans who served in the theater of operations (e.g., OEF/OIF/OND) like
other Veterans may provide income information for assessment in order to have their priority for enrollment and financial eligibility for
travel assistance, cost-free medications and/or medical care for services unrelated to military experience.
VA FORM
FEB 2011

10-10EZR

Previous editions of this form are not to be used.

PAGE 1

VETERAN'S NAME

(Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION V - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1. SPOUSE'S NAME (Last,

First, Middle Name)

2. CHILD'S NAME

1A. SPOUSE'S MAIDEN NAME

2A. CHILD'S RELATIONSHIP TO YOU

Son

1B. SPOUSE'S SOCIAL SECURITY NUMBER

1C. SPOUSE'S DATE OF BIRTH

(Last, First, Middle Name)

Daughter

(Check one)
Stepson

2B. CHILD'S SOCIAL SECURITY NUMBER

(mm/dd/yyyy)

1D. DATE OF MARRIAGE

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street,

(mm/dd/yyyy)

Stepdaughter

2C. DATE CHILD BECAME YOUR DEPENDENT

(mm/dd/yyyy)

2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?

City, State, ZIP )

YES

NO

2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST
CALENDAR YEAR?

YES

YES

NO

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
REHABILITATION OR TRAINING (e.g., tuition, books, materials)

3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID
YOU PROVIDE SUPPORT?

$

NO

SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
SPOUSE

VETERAN
1. GROSS ANNUAL INCOME FROM EMPLOYMENT (eg., wages, bonuses, tips, etc.)
EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS.

CHILD 1

$

$

$

2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS.

$

$

$

3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation,
pension, interest, dividends). EXCLUDING WELFARE.

$

$

$

SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
(e.g., payments for doctors, dentists,
medications, Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses
you may claim.

1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE LAST CALENDAR YEAR

$

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED
SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section V.)

$

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES
materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

$

(e.g., tuition, books, fees,

SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
VETERAN

CHILD 1

SPOUSE

1. CASH AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,
certificates of deposit, individual retirement accounts, stocks and bonds)

$

$

$

2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS. (e.g.,
second homes and non-incoming producing property. Do not count your primary home.)

$

$

$

3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectables) MINUS
THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH OR
BUSINESS ASSETS. Exclude household effects and family vehicles.

$

$

$

SECTION IX - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB
number. We anticipate that the time expended by all individuals who must complete this form will average 24 minutes. This includes the time it will take to read instructions,
gather the necessary facts and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1710, 1712, and 1722 in order for VA to determine your
eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as
permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA
Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of
your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled If you provide VA your
Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits
and their records, and for other purposes authorized or required by law.

SECTION X --CONSENT TO COPAYMENTS
By signing this application you are agreeing to pay the applicable VA copays for treatment or services for your NSC conditions as required by law.
SECTION XI - ASSIGNMENT OF BENEFITS
I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan
(HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby
authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges
for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who
is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my
right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby
appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate
actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party or administrative
agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I
hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.
SIGNATURE OF APPLICANT

VA FORM
FEB 2011

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.

10-10EZR

DATE (mm/dd/yyyy)

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